ORIGINAL ARTICLE
https://doi.org/10.4306/pi.2017.14.1.44
Print ISSN 1738-3684 / On-line ISSN 1976-3026 OPEN ACCESS
Prevalence of Metabolic Syndrome in Patients with Schizophrenia in Korea: A Multicenter Nationwide Cross-Sectional Study Jung Sun Lee1, Jun Soo Kwon2, Daeho Kim3, Sung-Wan Kim4, Jae-Jin Kim5, Jong-Hoon Kim6, Hee Jung Nam7, Seunghyong Ryu8, Il Ho Park9, Suk Kyoon An5, Hong-Seok Oh10, Seunghee Won11, Kanguk Lee12, Kyu Young Lee13, Seung-Hwan Lee14, Yu Sang Lee10, Jung-Seo Yi15, Kyung Sue Hong8, and Yeon Ho Joo1 Department of Psychiatry, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea Department of Psychiatry, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea 3 Department of Psychiatry, College of Medicine, Hanyang University, Hanyang University Medical Center, Seoul, Republic of Korea 4 Department of Psychiatry, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea 5 Department of Psychiatry, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Republic of Korea 6 Department of Psychiatry, Gil Medical Center, Gachon University School of Medicine, Neuroscience Research Institute, Gachon University, Incheon, Republic of Korea 7 Department of Psychiatry, Seoul Medical Center, Seoul, Republic of Korea 8 Department of Psychiatry, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea 9 Department of Psychiatry & Behavioral Neuroscience, Catholic Kwandong University, International St. Mary’s Hospital, Incheon, Republic of Korea 10 Yongin Psychiatric Research Institute, Yongin Mental Hospital, Yongin, Republic of Korea 11 Department of Psychiatry, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea 12 Department of Psychiatry, Kangwon National University School of Medicine, Kangwon National University Hospital, Chuncheon, Republic of Korea 13 Department of Psychiatry, Eulji University School of Medicine, Eulji General Hospital, Seoul, Republic of Korea 14 Department of Psychiatry, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, Republic of Korea 15 Department of Psychiatry, College of Medicine, Hallym University, Kangnam Sacred Heart Hospital, Seoul, Republic of Korea 1 2
ObjectiveaaWe designed a nationwide study with limited exclusion criteria to investigate the prevalence of metabolic syndrome (MetS)
in Korea and its relationship with antipsychotic medications. MethodsaaThis multicenter, cross-sectional, and observational study included patients diagnosed with schizophrenia or schizoaffective disorder. Sixteen hospitals enrolled 845 patients aged 18 to 65 years prescribed any antipsychotic medication between August 2011 and August 2013. MetS was diagnosed using the criteria of the modified Adult Treatment Panel III of the National Cholesterol Education Program with the Korean abdominal obesity definition (waist circumference ≥85 cm in women, ≥90 cm in men). ResultsaaThe prevalence of MetS in all patients was 36.5% and was significantly higher in men than women (men, 40.8%; women, 32.2%) and was significantly correlated with age [odds ratio (OR) 1.02] and duration of illness (OR 1.03). The prevalence of MetS across antipsychotic drugs in the major monotherapy group was as follows: 18.8% for quetiapine, 22.0% for aripiprazole, 33.3% for both amisulpride and paliperidone, 34.0% for olanzapine, 35% for risperidone, 39.4% for haloperidol, and 44.7% for clozapine. ConclusionaaThe prevalence of MetS is very high in patients with schizophrenia or schizoaffective disorder. Screening and monitoring Psychiatry Investig 2017;14(1):44-50 of MetS is also strongly recommended. Key WordsaaMetabolic syndrome, Antipsychotics, Korean population, Schizophrenia, Schizoaffective disorder.
INTRODUCTION Patients with schizophrenia have a reduced life expectancy for several reasons, including increased incidence of accidents,
cardiovascular disease (CVD), and infectious disease.1 In particular, CVD is one of the most important causes of mortality and is responsible for about 45% of the excess mortality of schizophrenia.2 Patients with schizophrenia show 2−3 times
Received: February 19, 2016 Revised: May 2, 2016 Accepted: June 3, 2016 Available online: July 26, 2016 Correspondence: Yeon Ho Joo, MD, PhD
Department of Psychiatry, University of Ulsan College of Medicine, Asan Medical Center, 88 Oylimpic-ro, Songpa-gu, Seoul 05505, Republic of Korea Tel: +82-2-3010-3410, Fax: +82-2-485-8381, E-mail:
[email protected] cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
44 Copyright © 2017 Korean Neuropsychiatric Association
JS Lee et al.
higher risk of CVD than healthy controls.1 Many factors, including poor diet, tobacco smoking, weight gain, and low physical exercise, affect CVD development in patients with schizophrenia.3-5 Recently, several medications, especially antipsychotics, have been identified as having a negative impact on the development of CVD.6,7 Several comprehensive reviews concluded that atypical antipsychotics significantly increased the risk of certain CVDs, such as diabetes, compared with typical antipsychotics.6,8 Some studies also reported a higher prevalence of diabetes and hypertension in patients with schizophrenia than healthy controls.3,9,10 This increased prevalence of CVD, diabetes, and hypertension and increased mortality may be partially due to Metabolic Syndrome (MetS). MetS includes five major components: 1) abdominal obesity; 2) hypertension; 3) increased fasting glucose level; 4) hypertriglyceridemia; and 5) decreased highdensity lipoprotein (HDL). The prevalence of MetS in patients with schizophrenia is 2−4 times higher than in healthy individuals.8,11-13 The prevalence of MetS in patients with schizophrenia varies across studies: 35.4% in the Netherlands,14 32.3% in Belgium,15 40.9% in the United States CATIE study,12 22.8% in Thailand,16 27.5% in Japan,17 and 31.7% in Korea.13 The causes of this variety in the prevalence include the use of different definitions of MetS, such as that of the Adult Treatment Panel III report (ATP III) of the National Cholesterol Education Program,12,14 the modified ATP III,13,15,17 and the International Diabetes Federation (IDF).16 In addition, some studies of Asian patients used Asian or Korean criteria for abdominal obesity. MetS is also partially dependent on the location, lifestyle, and demographic characteristics of the patients, such as age, gender, and ethnicity.18-20 Patients in previous studies had very different demographic and clinical factors, such as mean age, male:female ratio, duration of illness, and prescribed antipsychotic medications. Finally, some studies investigated the prevalence of MetS in a limited number of patients or patients enrolled for other purposes and not for the actual study of this prevalence. Thus, there may have been a selection bias and the results from a limited number of patients or hospitals might not be generalizable. To overcome these limitations, we designed a nationwide study with minimal exclusion criteria and from multiple psychiatric units across the nation to investigate the prevalence of MetS in Korea and the relationship between psychiatric medication and MetS prevalence.
METHODS This study was a multicenter, cross-sectional, and observational study of patients diagnosed with schizophrenia or
schizoaffective disorder according to Diagnostic and Statistical Manual of Mental Disorders-IV-Text Revision (DSM-IV-TR) diagnostic criteria. Sixteen hospitals−3 mental hospitals and 13 university-affiliated general hospitals−enrolled patients aged 18 to 65 years that had been prescribed any antipsychotic medication for the treatment of schizophrenia or schizoaffective disorder between August 2011 and August 2013. Of the 892 patients who consented to participate in the study, we excluded 47 due to a lack of information, such as age, gender, blood pressure (BP), waist circumference, or blood laboratory results. Written informed consent was obtained from all patients and this study was approved by the Institutional Review Board of each hospital. Patient demographic data and histories were obtained from their medical records and by interview. We asked the patients if they had any conditions such as diabetes, dyslipidemia, or hypertension, or were overweight when they enrolled in this study. Based on the patients’ reports, we divided these subjects into “patients with no medical disease” and “patients with medical disease”. Waist circumference was measured at the umbilical level in a standing position and BP was measured using standard mercury sphygmomanometers or clinically approved automatic BP devices after a 5-minute rest. Plasma HDL cholesterol, triglycerides, and fasting blood glucose were also measured after at least 8-hour fast. MetS was diagnosed with the definitions of the modified ATP III for Korea (three or more of the following five criteria):21 waist circumference ≥85 cm in women or ≥90 in men, fasting blood glucose ≥100 mg/dL or specific treatment for hyperglycemia, serum triglyceride ≥150 mg/dL or specific treatment for a lipid abnormality, HDL
